Adult ICUs Research Articles

G222 Does the implementation of a ventilator associated pneumonia (vap) care bundle reduce incidence of vap in picu?

Ventilator associated pneumonia (VAP) is pneumonia that develops 48 h after intubation. VAP is the second most common nosocomial infection in PICU patients and is associated with increased duration of ventilation, ICU stay, hospital stay, and cost. VAP is a preventable healthcare acquired infection and a Department of Health (1999) Saving Lives initiative. This poster aims to discover whether the introduction of a VAP care bundle (VCB) is effective at reducing VAP rates in PICU. A search of various databases was undertaken, including MedLine, Pubmed, CINHAL, EBSCO, using relevant PICO key words. 3 paediatric research studies were found and 4 published presentations of data. Due to the limited amount of paediatric data the search was extended to include adult studies, producing 12 valid studies. Results conclusively showed a decrease in VAP following the introduction of a VAP care bundle. Paediatric studies showed a reduction ranged from 76%–100% (91% average), with 210 days – 3 years VAP free with associated decreases in length of stay and cost. Adult studies found a 62% average decrease in VAP, with higher reduction in VAP associated with increased compliance. Due to limitations of the observational designs used, various implementation strategies, and lack of consistency in VCB elements, it is difficult to determine what is responsible for the measured outcomes. However the weight of evidence showing VAP reduction with VCB use suggests a strong relationship. And although the evidence is not at the highest experimental level, it is at the highest ethically acceptable level. It should also be taking into consideration that each individual bundle component is supported by its own breadth of high level experimental evidence. Routine use of VCB is widespread in adult ICUs, and the adult and paediatric literature agree that care bundles are an effective method for reducing the incidence of ventilator associated pneumonia. Therefore in absence of any contradictory data, care bundles should be adopted in paediatric intensive care practice. Further research is required to examine individual elements of the paediatric VCB; but with a synchronised team approach, VCB can result in continued reductions in VAP, length of stay, and costs.

Increasing frequency of Pseudomonas aeruginosa infections during tigecycline use.

The widespread use of tigecycline raises the question of increasing infection rates of Pseudomonas aeruginosa (PA) in ICUs which are not affected by this antibiotic. The aim of this study was to determine if treatment with tigecycline is a risk factor for PA infection in ICU patients. A retrospective and observational study was conducted at Erciyes University Hospital, Turkey, between 2008 and 2010. The Erciyes University Hospital is a 1300-bed tertiary care facility. The patients included in this study were hospitalized in four adult ICUs. Patients with PA infections (case group) were compared with patients with nosocomial infection other than PA (control group). A total of 1,167 patients with any nosocomial infections were included in the study. Two hundred and seventy eight (23.8%) of the patients had PA infection during their ICU stay. Fifty nine patients (21.2%) in the case group received tigecycline before developing PA infections, which were found to be significantly more frequent than in the controls (p < 0.01). Multivariate analysis showed that risk factors for PA infection were previous tigecycline use (4 times), external ventricular shunt (4.2 times), thoracic drainage catheter (2.5 times) and tracheostomy (1.6 times). Our results contribute to the need for new studies to determine the safety of tigecycline use, especially for the treatment of critically ill patients. Since tigecycline seems to be an alternative for the treatment of multidrug resistant (MDR) microorganisms, rational use of this antibiotic in ICU patients is essential.

Epidemiological Characteristics, Resistance Patterns and Spread of Gram-Negative Bacteria Related to Colonization of Patients in Intensive Care Units

Our aim was to determine the epidemiological characteristics, the resistance patterns and the spread of Gram negative bacteria related to colonization of patients in adult Intensive Care Units. Methods: A prospective cohort of patients colonized and/or infected with Gram negative bacteria was conducted at two adult ICUs from hospitals in Brazil (April 2012 to February 2013). Nasal, groin and perineum swabs were performed. Samples were incubated on MacConkey and cetrimide agar (48 h at 37℃) and identification tests (Vitek-BioMerieux), antibiogram (Bauer-Kirby method), Carba NP test, Polymerase Chain Reaction (PCR) and sequencing were performed. The patterns of resistant microorganisms were compared by rep-PCR (Diversilab). Results: There were 53 cases of colonization. In these cases, we identified imipenem-resistant Acinetobacter baumannii (51%), Pseudomonas aeruginosa (32%), Klebsiella pneumoniae ESBL (38%) or imipenem resistant (5.6%). The use of antimicrobials and medical devices were related to colonization (p < 0.05). The resistance patterns expressed by Klebsiella pneumoniae were ESBL (CTX-M, SHV e TEM) and KPC2. A verified profile of Acinetobacter baumannii was related to OXA-23 and OXA-253 (OXA-143 variant). The profiles ESBL and KPC2 expressed by Klebsiella pneumoniae were distributed between the both ICUs. The distribution of OXA-23 and OXA-253 was verified only in one ICU. The similarity of strains ranged from 80% to 95%, highlighting the horizontal transference of these microorganisms.

Antifungal susceptibility, risk factors and treatment outcomes of patients with candidemia at a university hospital in Saudi Arabia

Background: Candidemia is a major cause of morbidity and mortality in hospitalized patients. The spectrum of candidemia has been changed especially among critically ill patients due to emergence of non-albicans Candida (NAC) species. The increasing use of azole agents is suggested to be responsible for this epidemiological shift. NAC species are of special concern because of their high drug-resistance and increasing prevalence.The aim of this study was to detect antifungal-susceptibility patterns, treatment outcomes and associated risk factors in patients with candidemia who were admitted to King Abdulaziz University Hospital (KAUH), Jeddah, Kingdom of Saudi Arabia (KSA) .Methods: This work represents a cross sectional study done in the Clinical and Microbiology Laboratory at KAUH, during the periodfrom March 2012 till February 2014 on a total of 141 patients with candidemia. They were 31(22%) Saudi and 110(87%) non-Saudi patients with age ranged from 1 day - 102 years. Blood cultures were collected for suspected cases of candidemia, followed by subculture on SDA. Identifiation was done by VITEK MS (MALDI-TOF MS), and confimation of Candida isolates and antifungal-susceptibility testing were performed by using VITEK ®2 system.Results: C.albicans isolates accounted for 39.7%, followed by C. tropicalis (21.3%), C. galabrata (18.4%) and C. parapsiliosis (14.9%). Additionally, C. dublinsis, C. krusei and C. famata were representing 2.1%, 2.1% and 1.4%, respectively. All Candida isolates were 100% susceptible to amphotericin B. The best susceptibility to flconazole was detected among each C. dubliensis and C. famata (100%). All C. krusei isolates were resistant to flconazole, while they were susceptible  to other antifungal agents. All isolates were susceptible to flcytosine,except C. albicans and C. dubliensis which were susceptible 92.9%and 66.7%, respectively. All isolates were susceptible to itraconazol,except C. albicans and C. tropicalis which were susceptible 94.6% and 96.7%, respectively. The percentage of deceased patients with candidemia was signifiantly higher than the survivors among age group >64 years, particularly those who were mechanically ventilated and those understeroid therapy. The percentage of deceased patients was signifiantly higher than survivors among those admitted to adult ICUs (73.78%vs 26.23%) .Conclusion: This study shows an epidemiological shift to higher NAC species isolation rates, with 100% susceptibility to amphotericin B in all isolates either C. albicans or NAC species, and 100% susceptibility to flconazole among C. dubliensis and C. famata. Patients aged > 64 years, admission to adult ICUs, mechanical ventilation and steroid therapy were signifiant risk factors for increased mortality due to candidemia.

Impact of self-reported guideline compliance: Bloodstream infection prevention in a national collaborative

We sought to examine self-reported compliance with 5 evidence-based central line-associated bloodstream infection (CLABSI) prevention practices and link compliance to CLABSI rates in a national patient safety collaborative. We analyzed data from a national CLABSI prevention program. Adult ICUs participating in the program submitted their CLABSI rates and a Team Checkup Tool (TCT) on a monthly basis. The TCT responses provided self-reported perceptions about how reliably the unit team performed the evidence-based practices in the previous month. Monthly data were aggregated into quarters for the analysis. We analyzed a total of 2775 ICU quarters during the program. Chlorhexidine skin preparation and hand hygiene had the highest adherence. Avoidance of the femoral site and removal of unnecessary lines had the lowest compliance. Regression results showed that consistent performance of all practices was significantly associated with lower CLABSI rates. In terms of each practice's independent effect, femoral site avoidance for line placement and removal of unnecessary lines were independently associated with lower CLABSI rates after controlling for other factors. Our findings suggest that uptake of the 2 low-compliance practices, avoidance of the femoral site and removal of unnecessary lines, is important for reducing CLABSI rates in conjunction with other practices.

Relationship between ICU bed availability, ICU readmission, and cardiac arrest in the general wards.

The decision to admit a patient to the ICU is complex, reflecting patient factors and available resources. Previous work has shown that ICU census does not impact mortality of patients admitted to the ICU. However, the effect of ICU bed availability on patients outside the ICU is unknown. We sought to determine the association between ICU bed availability, ICU readmissions, and ward cardiac arrests. In this observational study using data collected between 2009 and 2011, rates of ICU readmission and ward cardiac arrest were determined per 12-hour shift. The relationship between these rates and the number of available ICU beds at the start of each shift (accounting for census and nursing capacity) was investigated. Grouped logistic regression was used to adjust for potential confounders. Five specialized adult ICUs comprising 63 adult ICU beds in an academic medical center. Any patient admitted to a non-ICU inpatient unit was counted in the ward census and considered at risk for ward cardiac arrest. Patients discharged from an ICU were considered at risk for ICU readmission. None. Data were available for 2,086 of 2,190 shifts. The odds of ICU readmission increased with each decrease in the overall number of available ICU beds (odds ratio = 1.06; 95% CI, 1.00-1.12; p = 0.03), with a similar but not statistically significant association demonstrated in ward cardiac arrest rate (odds ratio = 1.06; 95% CI, 0.98-1.14; p = 0.16). In subgroup analysis, the odds of ward cardiac arrest increased with each decrease in the number of medical ICU beds available (odds ratio = 1.26; 95% CI, 1.06-1.49; p = 0.01). Reduced ICU bed availability is associated with increased rates of ICU readmission and ward cardiac arrest. This suggests that systemic factors are associated with patient outcomes, and flexible critical care resources may be needed when demand is high.

Inappropriate Care in European ICUs: Confronting Views From Nurses and Junior and Senior Physicians

ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power.We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations.By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups.ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.

Thrombosis Prophylaxis and Mortality Risk Among Critically Ill Adults

The optimal approach for managing increased risk of VTE among critically ill adults is unknown. An observational study of 294,896 episodes of critical illness among adults was conducted in 271 geographically dispersed US adult ICUs. The primary outcomes were all-cause ICU and in-hospital mortality after adjustment for acuity and other factors among groups of patients assigned, based on clinical judgment, to prophylactic anticoagulation, mechanical devices, both, or neither. Outcomes of those managed with prophylactic anticoagulation or mechanical devices were compared in a separate paired, propensity-matched cohort. After adjustment for propensity to receive VTE prophylaxis, APACHE (Acute Physiology and Chronic Health Evaluation) IV scores, and management with mechanical ventilation, the group treated with prophylactic anticoagulation was the only one with significantly lower risk of dying than those not provided VTE prophylaxis (ICU, 0.81 [95% CI, 0.79-0.84]; hospital, 0.84 [95% CI, 0.82-0.86; P < .0001). The mortality risk of those receiving mechanical device prophylaxis was not lower than that of patients without VTE prophylaxis. A study of 87,107 pairs of patients matched for propensity to receive VTE prophylaxis found that those managed with prophylactic anticoagulation therapy had significantly lower risk of death (ICU subhazard ratio, 0.82 [95% CI, 0.78-0.85]; hospital subhazard ratio, 0.82 [95% CI, 0.79-0.85]; P < .001) than those receiving only mechanical device prophylaxis. These findings support a recommendation for prophylactic anticoagulation therapy in preference to mechanical device prophylaxis for critically ill adult patients who do not have a contraindication to anticoagulation.

The Interaction of Vasopressin and Corticosteroids in Septic Shock

Vasopressin and corticosteroids are both commonly used adjunctive therapies in septic shock. Retrospective analyses have suggested that there may be an interaction between these drugs, with higher circulating vasopressin levels and improved outcomes in patients treated with both vasopressin and corticosteroids. We aimed to test for an interaction between vasopressin and corticosteroids in septic shock. Prospective open-label randomized controlled pilot trial. Four adult ICUs in London teaching hospitals. Sixty-one adult patients who had septic shock. Initial vasopressin IV infusion titrated up to 0.06 U/min and then IV hydrocortisone (50 mg 6 hourly) or placebo. Plasma vasopressin levels were measured at 6-12 and 24-36 hours after hydrocortisone/placebo administration. Thirty-one patients were allocated to vasopressin + hydrocortisone and 30 patients to vasopressin + placebo. The hydrocortisone group required a shorter duration of vasopressin therapy (3.1 d; 95% CI, 1.1-5.1; shorter in hydrocortisone group) and required a lower total dose of vasopressin (ratio, 0.47; 95% CI, 0.32-0.71) compared with the placebo group. Plasma vasopressin levels were not higher in the hydrocortisone group compared with the placebo group (64 pmol/L difference at 6- to 12-hour time point; 95% CI, -32 to 160 pmol/L). Early vasopressin use was well tolerated with only one serious adverse event possibly related to study drug administration reported. There were no differences in mortality rates (23% 28-day mortality in both groups) or organ failure assessments between the two treatment groups. Hydrocortisone spared vasopressin requirements, reduced duration, and reduced dose, when used together in the treatment of septic shock, but it did not alter plasma vasopressin levels. Further trials are needed to assess the clinical effectiveness of vasopressin as the initial vasopressor therapy with or without corticosteroids.

Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility Bundle*

The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice. Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012. Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center. Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions' medical or surgical critical care service. Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle. For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median [interquartile range], 24 [7-26] vs 21 [0-25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33-0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29-3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates. Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.

Risk Factors and Outcome Analysis of Acinetobacter baumannii Complex Bacteremia in Critical Patients*

Acinetobacter baumannii complex bacteremia has been identified increasingly in critical patients admitted in ICUs. Notably, A. baumannii complex bacteremia has a high mortality rate, yet the risk factors associated with mortality remain unclear and controversial. Retrospective study. All adult ICUs at a tertiary care medical center. All patients with A. baumannii complex bacteremia admitted in 2009-2010. None. Risk factors for mortality were analyzed. Bacterial isolates were identified by 16S-23S ribosomal RNA intergenic spacer region sequencing for genospecies and genotyped by pulsed-field gel electrophoresis. Carbapenemase genes were detected by polymerase chain reaction and sequencing. A total of 298 patients met the inclusion criteria, including 73 (24.5%) infected by imipenem-resistant A. baumannii complex. The overall 30-day mortality was 33.6% (100 of 298). Imipenem-resistant A. baumannii complex bacteremia specifically showed a high mortality (69.9%) and was associated with prior use of broad-spectrum antibiotics for more than 5 days for treating ventilator-associated pneumonia before the occurrence of bacteremia. Mortality was associated with inappropriate initial antimicrobial therapy, which was correlated with imipenem-resistant A. baumannii complex but not with any specific genospecies. ISAba1-blaOXA-23-ISAba1 (Tn2006) was found in most (66.7%, 40 of 68) imipenem-resistant A. baumannii (genospecies 2) and also spread beyond species border to all imipenem-resistant genospecies 3 (2), 13TU (2), and 10 (1). For critical patients with A. baumannii complex infection, ventilator-associated pneumonia in particular, the selective pressure from prior use of broad-spectrum antibiotics for 5 days or more increased risk of subsequent imipenem-resistant A. baumannii complex bacteremia. To reduce mortality, rapid identification of imipenem-resistant A. baumannii complex and early initiation of appropriate antimicrobial therapy in these high-risk patients are crucial.

Use of endotracheal tubes in continuous aspiration of subglottic secretions: Knowledge and expertise of respiratory therapists and nurses

Introduction: Ventilator-associated pneumonia (VAP) is a hospital acquired nosocomial infection that is commonly found in patients receiving mechanical ventilation. Continuous aspiration of subglottic secretions (CASS) is found to lower the incidence of VAP. The aim of this study was to assess respiratory therapists and nurses’ awareness and experiences about the Endotracheal Tubes (ETT) with CASS. Methodology: This is a cross-sectional study. Purposive sampling of 51 respiratory therapists and 51 nurses who were involved in taking care of critically ill patients in adult ICUs at King Abdul-Aziz Medical City, Riyadh were used. The questionnaire was related to the knowledge and experiences of respiratory therapists and nurses about the proper use of ETT with CASS. Results: The results suggest that the respiratory therapists were more knowledgeable in the use of ETT-CASS. However, both respiratory therapists and nurses had problems related to ETT design and materials. Most of these problems were related to cuff materials and its design, suctioning system and tubes, in addition to the availability of the equipment. Conclusion: This study presents a unique contribution to knowledge about the experiences of respiratory therapists and nurses who work in KAMC about the proper use of ETT-CASS. The results of this study showed that the use of ETT-CASS is yet to be popularly recognized. Thus, it should be acclaimed by further studies and promotion through formulation of updated protocols and educational programs.

Implementing a point of care testing (POCT) service improves management of haemostatic dysfunction in cardiac surgery patients

s / Australian Critical Care 27 (2014) 43–63 49 concentration prepared, who usually prepared the drug and what current safety practices were used. Results:Thirty-eight responses to the surveywere received representing 29 ICUs, approximately 17% of all adult ICUs in Australia and NZ. Two specialist peadiatric ICUs also responded. Seventeen respondents (60%) were currently using at least one pre-prepared infusion, most commonly heparin (8/17), epidurals (6/17) or opiates for patient controlled analgesia (11/17). Significant variation in final concentration was observed for all infusionsexcept insulinandesmolol. Thefinal volumevaried significantly for all drugs. Other than the small number of pre-prepared infusions, nursing staff prepared all infusions. Labellingwas usually hand-written with some colour-coding. Ninety percent of respondents identified safety and 68% identified efficiency as likely to be improved by the use of pre-prepared infusions. Conclusion: Significant variation exists in the preparation of commonly used infusions across ICUs in Australia andNZ. Rationalisation and standardisation of practice would improve safety and efficiency. A nationally or regionally coordinated response could potentially reduce the barrier of cost. Disclosureof interest:Anunrestricted researchgrant fromBaxter HealthCare supported the conduct of this study. http://dx.doi.org/10.1016/j.aucc.2013.10.019 Implementing a point of care testing (POCT) service improves management of haemostatic dysfunction in cardiac surgery patients B. Pearse1,∗, D. Wall1, I. Smith1, D. Faulke1, I. Rapchuck1, J. Fraser2, J. McGree3, L. Drake1, P. Tesar1, Yl. Fung2 1 The Prince Charles Hospital, Brisbane, Australia 2 Critical Care Research Group, UQ, 7 School of Mathematical Sciences, QUT, Australia 3 Critical Care Research Group, UQ, Australia Introduction:Somebleeding is anexpectedconsequenceof cardiac surgery. Excessive or uncontrolled bleeding is a complication requiring timelymanagement andmay require blood transfusion/s. Turnaround times for standard laboratory tests (SLT’s) is often too slow to guide treatment. Hence, blood products are often transfused before SLT results are available. Blood product transfusion is not without risk and is independently associated with increased risk for morbidity/mortality. Objectives: To improve diagnosis of haemostatic dysfunction and bleeding management, in July 2012 we commenced the implementation of a clinician driven POCT service using rotationalthromboelastometry (ROTEM) and platelet function (Multiplate) at The Prince Charles Hospital. Methods: A multidisciplinary, multimodal approach was taken and involved appointment of a project lead, identifying stakeholders, developing a project plan, educating POCT operators/interpreters, developing quality control infrastructure and monitoring/analysing outcomes. Results: A comparison of post POCT implementation data with historical controls demonstrated a decrease in percentage patients receiving RBC’s (p=2.965e−08), FFP (p<2.2e−16) and platelets (p<2.2e−16). Units per patient was reduced for RBC (p=1.8413e−09), FFP (p=5.4988e−25) and platelets (p=8.5073e−27). A significant decrease was seen in reexploration rate for bleeding (p=0.0509) and median hospital LOS (p=9.3657e−09). Conclusions: Implementation of our POCT service reduced percentage of patients receiving blood products as well as quantity of products transfused. Timely results allowedclinicians to treat coagulopathy,with only those products required to resolve haemostatic dysfunction. Key to this success is a dedicated project lead and a multidisciplinary, multimodal approach involving all stakeholders. http://dx.doi.org/10.1016/j.aucc.2013.10.020 Measurement of temperature in critically ill adults: A systematic review and clinical practice guideline K. Rolls1,∗, K. Armstrong2, L. Keating3, D. Wrightson4, S. Walker5, J. Masters1 1 ACI-ICCMU, Australia 2 Bankstown ICU, Australia 3 St George ICU, Australia 4 Wollongong ICU, Australia 5 Central Queensland University, Australia Accurate measurement of temperature is important to ensure patients receive appropriate and timely interventions to prevent significantmorbidity andmortality. The clinical questionunderpinning this studywas ‘whatmethod/sofmeasuringbody temperature ensures the timely identification of abnormal temperatures in critically ill adults?’ An expert nursing group undertook a systematic review to identify research published between January 2000 and May 2012, published in English and applicable to critically ill patients aged more than 13. Recommendations for practice were developed at a consensus meeting and refined using internal and external validation panels. Online surveyswere usedwhere panellists indicated their level of agreementusinga9-point Likert scale. Agreementwas set as a median of equal or greater than seven. National Health and Medical Research Council guideline processes and evidence taxonomy were applied. Scottish Intercollegiate Guidelines Network quality criteria were used. Thirty-one paperswere reviewedwith 24, including 17 Level III2 studies, four systematic reviews and three guidelines, included in thefinal review. Themost commonproblemswere failure to ensure adequate inter-rater reliability and sample size, and application of Bland–Altman analysis.

Effectiveness of Self Instructional Module on Central Venous Catheter Care among ICU Nurses

Central venous catheters are often used as mandatory devices when caring critically ill patients. Catheter-related blood stream infections are associated with significantly increased morbidity, mortality, and expenditures. Despite technological advances, an estimated 250,000 catheter related blood stream infections occur annually. Advanced practice nurses possess the power to influence catheter-related line infections in their critical care units. Understanding current recommendations for catheter material selection, site selection, site preparation, and site care can affect rates of catheter-related bloodstream infections 3 . Central venous catheterization can be lifesaving but is associated with complication rates of approximately 15%. 10 A study done at Escort Heart Centre, New Delhi shows that mortality due to central venous catheter related blood stream infection was 22.9% as compared with 0.2% in non central venous catheter related blood stream infection 11 . Many Studies shows that education of nurses and proper care of central venous catheters can reduces infection rates by 41 to 66% in adult ICUs. Hence, this study was aimed to determine effectiveness of self instructional module on central venous catheter care. The aim of the study was to impart the current recommendation regarding nursing care of patient with central venous catheter among staff nurses working in ICU. An Evaluative approach was used for the present study. Using purposive sampling technique 50 samples were selected from Chettinad Hospital and Research institute, Tamil Nadu, India. The tool used was self administered questionnaire. The collected data was analyzed using descriptive and inferential statistics. The findings of the study revealed a significantly increase in the staff nurses knowledge score after administration of self instructional module. The mean pre test score was 9.80 % and the mean post test score was 16.58 % and the difference between pre test and post test knowledge score was 6.78%.Based on the objectives of the study the findings of the level of knowledge score on staff nurses shows that they were able to gain adequate knowledge. The study shows that the staff nurses in post test were having average of moderately 30 % knowledge and adequate 70 % of knowledge regarding nursing care of patients with central venous catheter. Self instructional module is effective in increasing the knowledge regarding nursing care of patients with Central venous catheter among staff nurses.

Significant changes in the practice of chest radiography in Dutch intensive care units: a web-based survey

BackgroundICU patients frequently undergo chest radiographs (CXRs). The diagnostic and therapeutic efficacy of routine CXRs are now known to be low, but the discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still ongoing. We performed a survey of Dutch intensivists on the current practice of chest radiography in their departments.MethodsWeb-based questionnaires, containing questions regarding ICU characteristics, ICU patients, daily CXR strategies, indications for routine CXRs and the practice of radiologic evaluation, were sent to the medical directors of all adult ICUs in the Netherlands. CXR strategies were compared between all academic and non-academic hospitals and between ICUs of different sizes. A comparison was made between the survey results obtained in 2006 and 2013.ResultsOf the 83 ICUs that were contacted, 69 (83%) responded to the survey. Only 7% of responding ICUs were currently performing daily routine CXRs for all patients, and 61% of the responding ICUs were said never to perform CXRs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine CXRs was assumed by intensivists to be lower than 10% or to be between 10 and 20%. The efficacy of ‘on-demand’ CXRs was assumed to be between 10 and 60%. There is a consensus between intensivists to perform a routine CXR after endotracheal intubation, chest tube placement or central venous catheterization.ConclusionThe strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from being a common practice in 2006 to a rare current practice. Other routine strategies and an ‘on-demand only’ strategy have become more popular. Intensivists still assume the value of CXRs to be higher than the efficacy that is reported in the literature.

Haemodynamic monitoring in the intensive care unit: results from a web-based Swiss survey.

Background. The aim of this survey was to describe, in a situation of growing availability of monitoring devices and parameters, the practices in haemodynamic monitoring at the bedside. Methods. We conducted a Web-based survey in Swiss adult ICUs (2009-2010). The questionnaire explored the kind of monitoring used and how the fluid management was addressed. Results. Our survey included 71% of Swiss ICUs. Echocardiography (95%), pulmonary artery catheter (PAC: 85%), and transpulmonary thermodilution (TPTD) (82%) were the most commonly used. TPTD and PAC were frequently both available, although TPTD was the preferred technique. Echocardiography was widely available (95%) but seems to be rarely performed by intensivists themselves. Guidelines for the management of fluid infusion were available in 45% of ICUs. For the prediction of fluid responsiveness, intensivists rely preferentially on dynamic indices or echocardiographic parameters, but static parameters, such as central venous pressure or pulmonary artery occlusion pressure, were still used. Conclusions. In most Swiss ICUs, multiple haemodynamic monitoring devices are available, although TPTD is most commonly used. Despite the usefulness of echocardiography and its large availability, it is not widely performed by Swiss intensivists themselves. Regarding fluid management, several parameters are used without a clear consensus for the optimal method.

Role of Diabetes in the Development of Acute Respiratory Distress Syndrome*

Diabetes has been associated with decreased development of acute respiratory distress syndrome in some, but not all, previous studies. Therefore, we examined the relationship between diabetes and development of acute respiratory distress syndrome and whether this association was modified by type of diabetes, etiology of acute respiratory distress syndrome, diabetes medications, or other potential confounders. Observational prospective multicenter study. Four adult ICUs at two tertiary academic medical centers. Three thousand eight hundred sixty critically ill patients at risk for acute respiratory distress syndrome from sepsis, pneumonia, trauma, aspiration, or massive transfusion. None. Diabetes history was present in 25.8% of patients. Diabetes was associated with lower rates of developing acute respiratory distress syndrome on univariate (odds ratio, 0.79; 95% CI, 0.66-0.94) and multivariate analysis (adjusted odds ratio, 0.76; 95% CI, 0.61-0.95). After including diabetes medications into the model, diabetes remained protective (adjusted odds ratio, 0.75; 95% CI, 0.59-0.94). Diabetes was associated with decreased development of acute respiratory distress syndrome both in the subgroup of patients with sepsis (adjusted odds ratio, 0.77; 95% CI, 0.61-0.97) and patients with noninfectious etiologies (adjusted odds ratio, 0.30; 95% CI, 0.10-0.90). The protective effect of diabetes on acute respiratory distress syndrome development is not clearly restricted to either type 1 (adjusted odds ratio, 0.50; 95% CI, 0.26-0.99; p = 0.046) or type 2 (adjusted odds ratio, 0.77; 95% CI, 0.60-1.00; p = 0.050) diabetes. Among patients in whom acute respiratory distress syndrome developed, diabetes was not associated with 60-day mortality on univariate (odds ratio, 1.11; 95% CI, 0.80-1.52) or multivariate analysis (adjusted odds ratio, 0.81; 95% CI, 0.56-1.18). Diabetes is associated with a lower rate of acute respiratory distress syndrome development, and this relationship remained after adjusting for clinical differences between diabetics and nondiabetics, such as obesity, acute hyperglycemia, and diabetes-associated medications. In addition, this association was present for type 1 and 2 diabetics and in all subgroups of at-risk patients.

Eighteen Years of Experience With Acinetobacter baumannii in a Tertiary Care Hospital*

To characterize the descriptive and molecular epidemiology of Acinetobacter baumannii in our hospital. Longitudinal analysis of electronic microbiology laboratory records and isolates. A 1,500 bed public teaching hospital in the Miami area. Consecutive patients with A. baumannii from January 1994 to December 2011. None : Data on all A. baumannii isolates were clustered at the patient level, and the first isolate per single patient was determined. Yearly trends were analyzed based on carbapenem susceptibilities and originating units for all first isolates and first blood isolates per unique patient. Additionally, carbapenem nonsusceptible isolates frozen in the microbiology laboratory since 1998 were retrieved and evaluated using polymerase chain reaction and randomly amplified polymorphic DNA techniques. A total of 9,334 A. baumannii isolates were detected, of which 4,484 isolates (48%) were identified as first positive isolates per unique patient. Most of the burden of disease was located in the ICUs (odds ratio, 2.64 [95% CI, 2.17-3.22]; p < 0.0001) and in the adult wards (odds ratio, 3.867 [95% CI, 2.71-5.52]; p < 0.0001). Respiratory specimens constituted the most frequent source (49%; odds ratio, 1.619 [95% CI, 1.391-1.884]; p < 0.0001). Of the 4,484 first isolates, 846 isolates (18.9%) were carbapenem nonsusceptible and 3,638 isolates (81.1%) were carbapenem susceptible. Over the years, the number of carbapenem nonsusceptible isolates increased, whereas the number of carbapenem susceptible decreased (p < 0.0001). The trauma ICU had the highest burden of carbapenem nonsusceptible first isolates (205 of 846; 24.2%). Seven clones were discovered among 144 carbapenem nonsusceptible isolates; one of these clones was found from 1999 to 2005. OXA-23 and OXA-40 were identified in 96 and 13 isolates, respectively. One isolate harbored a novel CTX-M-115 enzyme. This constitutes the largest experience with A. baumannii reported to date from a single center. Half of all isolates were respiratory specimens and were from adult ICUs, especially trauma. Even though this was a polyclonal process, a single clone was identified in the hospital through a 6-year span.

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Introduction: The purpose of this evaluation is to describe the cost savings associated with multimodal interventions aimed at reducing aerosolized bronchodilator use in mechanically ventilated patients without adversely affecting costs associated with length of stay. Methods: Subjects were included in the analysis if they were > 18 years of age; on mechanical ventilation in the ICU; and received aerosolized formulations of albuterol sulfate, ipratropium bromide or albuterol sulfate/ipratropium bromide. Patients were excluded if they had obstructive pulmonary disease as determined by appropriate ICD-9 codes. Results: There were 315 patients who received aerosolized bronchodilator therapy and 168 patients who did not receive aerosolized bronchodilator therapy after implementation of the multi-modal interventions to reduce inappropriate prescribing. Based on wholesale acquisition costs, the total cost of aerosolized bronchodilators dispensed to the adult ICUs over the 6 month post-intervention phase was reduced by $56,960 compared to the 6 month pre-intervention phase ($120,562 vs. $63,602, respectively). The annualized cost savings associated with multi-modal interventions designed to optimize aerosolized bronchodilator use in the adult ICUs is reported to be approximately $113,920. The actual observed lengths of both hospital (20 +/- 0.94 days vs. 11 +/- 1.23 days, p<0.001, respectively) and ICU (11 +/- 0.63 days vs. 5 +/- 0.58 days, p<0.001, respectively) stay were significantly longer in the group of patients that received bronchodilator therapy, but there was no significant change in the lengths of ICU stay (p=0.158) between a historical control comprised of consecutive ICU patients (n=449; 324 bronchodilator, 125 no bronchodilator) and the more recent cohort of patients evaluated after the multi-modal interventions to reduce bronchodilator use had been implemented. Conclusions: Multi-modal efforts to restrict aerosolized bronchodilator therapy in mechanically ventilated patients were successful and led to sustained reductions in use that was associated with substantial reductions in cost.

An attempt to validate the modification of the American-European consensus definition of acute lung injury/acute respiratory distress syndrome by the Berlin definition in a university hospital

The Berlin definition for acute respiratory distress syndrome (ARDS) is a new proposal for changing the American-European consensus definition but has not been assessed prospectively as yet. In the present study, we aimed to determine (1) the prevalence and incidence of ARDS with both definitions, and (2) the initial characteristics of patients with ARDS and 28-day mortality with the Berlin definition. We performed a 6-month prospective observational study in the ten adult ICUs affiliated to the Public University Hospital in Lyon, France, from March to September 2012. Patients under invasive or noninvasive mechanical ventilation, with PaO2/FiO2 <300 mmHg regardless of the positive end-expiratory pressure (PEEP) level, and acute onset of new or increased bilateral infiltrates or opacities on chest X-ray were screened from ICU admission up to discharge. Patients with cardiogenic pulmonary edema were excluded. Patients were further classified into specific categories by using the American-European Consensus Conference and the Berlin definition criteria. The complete data set was measured at the time of inclusion. Patient outcome was measured at day 28 after inclusion. During the study period 3,504 patients were admitted and 278 fulfilled the American-European Consensus Conference criteria. Among them, 18 (6.5 %) did not comply with the Berlin criterion PEEP ≥ 5 cmH2O and 20 (7.2 %) had PaO2/FiO2 ratio ≤200 while on noninvasive ventilation. By using the Berlin definition in the remaining 240 patients (n = 42 mild, n = 123 moderate, n = 75 severe), the overall prevalence was 6.85 % and it was 1.20, 3.51, and 2.14 % for mild, moderate, and severe ARDS, respectively (P > 0.05 between the three groups). The incidence of ARDS amounted to 32 per 100,000 population per year, with values for mild, moderate, and severe ARDS of 5.6, 16.3, and 10 per 100,000 population per year, respectively (P < 0.05 between the three groups). The 28-day mortality was 35.0 %. It amounted to 30.9 % in mild, 27.9 % in moderate, and 49.3 % in severe categories (P < 0.01 between mild or moderate and severe, P = 0.70 between mild and moderate). In the Cox proportional hazard regression analysis ARDS stage was not significantly associated with patient death at day 28. The present study did not validate the Berlin definition of ARDS. Neither the stratification by severity nor the PaO2/FiO2 at study entry was independently associated with mortality.